Medicare Advantage will be a coverage option for all Medicare ESRD beneficiaries starting in 2021

When Medicare Advantage (MA) was established in 2003, patients with end-stage renal disease (ESRD) were not eligible for these plans unless they were already enrolled in them when their kidneys failed, or if their employer-sponsored group health plan carrier also offered MA. That will change next year.

As part of the 21st Century Cures Act that was signed into law in 2016, all beneficiaries who qualify for Medicare due to ESRD will have the option to receive their coverage through a private MA plan, starting with the 2021 plan year.

MA plan types include health maintenance organizations (HMOs) and local preferred provider organizations (PPOs). Most MA enrollees are in HMOs or local PPOs.

These plans must provide the same Medicare Part A and Part B services covered in traditional Medicare and many also cover prescription drugs under Part D. They also can offer enrollees supplemental benefits that traditional Medicare does not cover, such as dental and vision benefits.

MA plans are required to establish provider networks, much like private insurers do. HMOs cover services provided by in-network providers only, while PPOs may cover out-of-network care with higher cost-sharing requirements for the enrollee. Traditional Medicare will cover Part A and Part B services provided by any participating Medicare provider.

Another difference between MA and traditional Medicare is that MA plans must limit enrollee out-of-pocket costs for Part A and Part B services to no more than $6,700 a year for in-network care, or $10,000 for in-network and out-of-network care combined. Traditional Medicare does not have an annual cap on patient out-of-pocket costs for deductibles, copayments and coinsurance. That’s why having Medigap supplemental coverage is critical for beneficiaries in traditional Medicare, especially ESRD patients who have more health care needs. Twenty states do not require insurers to offer Medigap coverage to ESRD patients under the age of 65, which means many ESRD patients do not have access to Medigap coverage.

Is Medicare Advantage the right choice for ESRD patients? There’s no single right answer. Comparing traditional Medicare and MA means taking a close look at important factors, and each patient should weigh them carefully: 

  • Access to health care providers
  • Premium costs
  • Out-of-pocket costs
  • MA options near you
  • Access to Medigap insurance (for traditional Medicare)
  • Supplemental benefits
  • Care management

For ESRD patients who need help understanding their Medicare options, State Health Insurance Assistance Programs (SHIPs) are a helpful resource. They provide free, local and objective health insurance counseling to people eligible for Medicare. Visit shiptacenter.org to find the contact information for your SHIP.

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About the Author

Mike Ly

Mike Ly is the Director of Public Policy at the American Kidney Fund

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